Quality statement 2: Exclusion from services

Quality statement

People aged 14 and over are not excluded from mental health services because of coexisting substance misuse or from substance misuse services because of coexisting severe mental illness.

Rationale

People with coexisting severe mental illness and substance misuse need age-appropriate support and expert care for these conditions. Appropriate care and support from mental health and substance misuse services will improve mental and physical health and medication adherence, and will reduce the risk of homelessness and dropout from services.

Quality measures

Structure

a) Evidence of local arrangements to ensure that people aged 14 and over are not excluded from substance misuse services on referral or when they present because of their severe mental illness.

Data source: Local data collection, for example, a local pathway for coexisting severe mental illness and substance misuse, joint working arrangements between mental health and substance misuse services, and service protocols.

b) Evidence of local arrangements to ensure that people aged 14 and over are not excluded from mental health services on referral or when they present because of their substance misuse.

Data source: Local data collection, for example, a local pathway for coexisting severe mental illness and substance misuse, joint working arrangements between mental health and substance misuse services, and service protocols.

Process

a) Proportion of referrals to substance misuse services for people aged 14 and over that are refused because of coexisting severe mental illness.

Numerator – the number in the denominator that are refused because of coexisting severe mental illness.

Denominator – the number of referrals to substance misuse services for people aged 14 and over with coexisting severe mental illness and substance misuse.

Data source: Local data collection, for example, audits of patient and referral records.

b) Proportion of referrals to mental health services for people aged 14 and over that are refused because of coexisting substance misuse.

Numerator – the number in the denominator that are refused because of coexisting substance misuse.

Denominator – the number of referrals to mental health services for people aged 14 and over with coexisting severe mental illness and substance misuse.

Data source: Local data collection, for example, audits of patient and referral records.

c) Proportion of people aged 14 and over presenting to substance misuse services who are not seen because of coexisting severe mental illness.

Numerator – the number in the denominator who are not seen because of coexisting severe mental illness.

Denominator – the number of people aged 14 and over with coexisting severe mental illness and substance misuse presenting to substance misuse services.

Data source: Local data collection, for example, audits of patient and clinic records.

d) Proportion of people aged 14 and over presenting to mental health services who are not seen because of coexisting substance misuse.

Numerator – the number in the denominator who are not seen because of coexisting substance misuse.

Denominator – the number of people aged 14 and over with coexisting severe mental illness and substance misuse presenting to mental health services.

Data source: Local data collection, for example, audits of patient and clinic records.

Outcome

a) Levels of physical health of people aged 14 and over with coexisting severe mental illness and substance misuse.

Data source: Local data collection, for example, audits of patient records. The Quality Outcomes Framework includes indicators on the physical health of people with severe mental illness. MH003 measures the percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of blood pressure in the preceding 12 months. MH006 measures the percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of BMI in the preceding 12 months.

b) Rates of medication adherence in people aged 14 and over with coexisting severe mental illness and substance misuse.

Data source: Local data collection, for example, audits of patient records.

c) Proportion of people aged 14 and over with coexisting severe mental illness and substance misuse in stable accommodation.

Numerator – the number in the denominator in stable accommodation.

Denominator – the number of people aged 14 and over with coexisting severe mental illness and substance misuse.

Data source: Local data collection, for example, audits of patient records. Public Health England's information on severe mental illness public health profile includes data on stable and appropriate accommodation for people on a care programme approach.

What the quality statement means for different audiences

Service providers (community, primary and secondary mental health services, including child and adolescent mental health services [CAMHS], and substance misuse services, including voluntary sector organisations) have policies and training in place to ensure that staff do not exclude people from the service because of severe mental illness or any substance misuse at point of referral or presentation to the service. They support and train staff to work with people with substance misuse and mental illness. They ensure that staff understand that people with coexisting severe mental illness and substance misuse may present with symptoms of severe mental illness or under the influence of alcohol or drugs. Providers ensure that staff know that people should not be excluded from the service because of this.

Mental health and substance misuse practitioners do not exclude people from a service because of severe mental illness or substance misuse. This applies at the point of referral and when people present to the service, even if they are severely intoxicated on presentation. Practitioners work with people with coexisting severe mental illness and substance misuse, and other services as needed, to ensure they provide the care and support required.

Commissioners (clinical commissioning groups, local authorities and NHS England) commission services for severe mental illness and for substance misuse and ensure that they have joint strategic working protocols so that people are not excluded from either service because of their coexisting condition. This applies at the point of referral and when they present to the service.

People aged 14 and over with severe mental illness and substance misuse are not refused care and support from a substance misuse or mental health service because of their mental illness or their drug or alcohol use. This means that they can receive care and support for both conditions at the same time.

Definitions of terms used in this quality statement

Severe mental illness

Severe mental illness includes a clinical diagnosis of schizophrenia, schizotypal and delusional disorders, bipolar affective disorder, or severe depressive episodes with or without psychosis.

[NICE's guideline on coexisting severe mental illness and substance misuse: community health and social care services, terms used in this guideline]

Substance misuse

Substance misuse refers to the use of legal or illicit drugs, including alcohol and medicine, in a way that causes mental or physical damage. This may include low levels of substance use that would not usually be considered harmful or problematic but may have a significant effect on the mental health of people with a mental illness such as psychosis.

[NICE's guideline on coexisting severe mental illness and substance misuse: community health and social care services, terms used in this guideline]

Exclusion from services

This includes refusal to accept a person for assessment or treatment because of the coexisting condition. This can be at the point of referral or when people attend for treatment. Most people aged 14 and over with coexisting severe mental illness and substance misuse will receive treatment for both conditions by healthcare professionals in secondary care mental health services such as community-based mental health teams, with input from substance misuse services if appropriate.

[Adapted from NICE's guideline on coexisting severe mental illness (psychosis) and substance misuse: assessment and management in healthcare settings, recommendation 1.4.5 and expert opinion]

Equality and diversity considerations

The symptoms of severe mental illness can be different in young people than in adults. Mental health and substance misuse professionals need to take this into account when working with young people, and should be aware that young people may present with quite subtle manifestations of mental illness. Professionals working with young people, for example, in the criminal justice system or substance misuse services, should have access to advice from a CAMHS team.